The most recent inspection on September 19, 2025, identified deficiencies related to failure to provide necessary care and medical attention to one resident experiencing pain and vomiting. Earlier inspections in 2025 included substantiated complaints about controlled medication misappropriation and issues with medication storage and supervision, including missing Morphine and Lorazepam from residents’ comfort kits. Inspectors cited failures to follow medication policies, store narcotics securely, and perform consistent shift-to-shift counts. The facility reported these incidents to police and has since implemented enhanced security measures and monitoring protocols for medications. The inspection history shows ongoing challenges with medication management and resident care, with some corrective actions taken after the complaint investigation.
Deficiencies (last 1 years)
Deficiencies (over 1 years)4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Illinois average
Illinois average: 3.5 deficiencies/year
Deficiencies per year
43210
2025
Inspection Report Original LicensingDeficiencies: 1Sep 19, 2025
Visit Reason
Original investigation of facility FRI IL 197269 to assess compliance with resident rights regulations.
Findings
The facility was found to have neglected one of three residents experiencing pain and vomiting, resulting in a Type 2 violation due to failure to provide necessary care and medical attention overnight.
Severity Breakdown
Type 2 VIOLATION: 1
Deficiencies (1)
Description
Severity
Failure to address one of three residents experiencing pain and vomiting, resulting in substantial probability of harm.
Type 2 VIOLATION
Employees Mentioned
Name
Title
Context
E3
Caregiver
Named in failure to follow protocol leading to resident pain and vomiting overnight.
E1
Executive Director
Expressed concerns about failure to follow protocol and stated termination of E3.
The inspection was conducted as a complaint investigation following substantiated incidents involving controlled medication misappropriation and failure to follow medication storage and supervision policies.
Findings
The facility failed to follow its policy and procedure on controlled medication storage and supervision, resulting in missing controlled substances (Morphine and Lorazepam) from residents' comfort kits. Narcotic lock boxes were stored in unlocked resident refrigerators, accessible to others, and shift-to-shift counts of controlled substances were not consistently performed. The incidents were reported to police but the establishment could not identify who took the medications.
Complaint Details
The complaint investigation was substantiated with findings of missing controlled substances from residents R16 and R17. The investigation revealed missing Morphine and Lorazepam, with evidence of tampering and missing narcotic sheets. The incidents were reported to police.
Severity Breakdown
Type 2 Violation: 2
Deficiencies (2)
Description
Severity
Failure to follow policy and procedure on controlled medication storage and supervision, including storing narcotic lock boxes in unlocked resident refrigerators accessible to others.
Type 2 Violation
Failure to prevent misappropriation of controlled medications paid for by residents, resulting in missing Morphine and Lorazepam from residents' comfort kits.
Type 2 Violation
Report Facts
Milliliters of Morphine missing: 28.75Milliliters of Lorazepam missing: 19.25Milliliters of Morphine missing: 30Milliliters of Morphine in lock box: 29.75Milliliters of Lorazepam in lock box: 30
Employees Mentioned
Name
Title
Context
E3
Director of Assisted Living and Memory Care
Provided information about medication storage practices and missing Morphine for resident R17
E4
Nurse
Provided information about narcotic counts and medication administration during the investigation
Inspection Report Plan of CorrectionDeficiencies: 1Feb 5, 2025
Visit Reason
Investigation of a self-reported incident related to medication administration at Lexington Square of Lombard.
Findings
A violation of Section 295.5000 & 295.6000 regarding medication administration was cited. The facility has implemented enhanced security and monitoring protocols for hospice comfort kit medications, including weekly audits and a double-lock security system.
Deficiencies (1)
Description
Violation of Section 295.5000 & 295.6000 Medication Administration
Employees Mentioned
Name
Title
Context
Carlos Bernal
Executive Director
Signed the plan of correction letter addressing medication administration violation.
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